An Idea Factory for Pathology Informatics and the Clinical Laboratory. Presented by the Pathology Education Consortium (PEC).

23 posts categorized "Blood Banking"

I started my career as a blood banker about 40 years ago. My job description was crystal clear at that time. My first, and most important task, was to ensure patient transfusion safety. This goal was accomplished with fail-safe patient blood typing and crossmatching of units intended for transfusion. My second important task was to help manage the blood inventory. This was accomplished by ensuring that there were a sufficient number of units in the blood bank based on anticipated need and also by limiting excessive and inappropriate physician blood orders. This latter task certainly had a flavor of clinical transfusion management but the clinicians usually got the product and number that they requested. Here's an excerpt of the description of a job candidate being sought by Santé Consultants that I received recently as an email:

Immediate Opening for a Manager of Blood Utilization/Patient Blood Management in the New York City region.

Santé Consulting has recently been retained by our client to conduct a nationwide search for a Manager of Blood Utilization and Patient Blood Management. Candidates must have MD, or MD, PhD degrees and be certified by the American Board of Pathology in Anatomic and Clinical Pathology or Clinical Pathology only, including Transfusion Medicine and Blood Banking....The job involves assistant directorial and management responsibilities of Transfusion Medicine laboratories; directorial and management responsibilities for the Medical Center Patient Blood Management Program; teaching pathology residents and conducting basic or patient-oriented translational research. The candidate will work closely with the Vice Chair of Clinical Pathology and Director of Blood Bank and Transfusion Service to expand and further modernize the Transfusion Medicine laboratories. This position reports to the Director of Blood Bank and Transfusion Services, and is responsible for directing the Patient Blood Management Program, and assisting in the direction of operations of the Blood Bank, Stem Cell and Immunogenetics laboratories of a major Academic Medical Center.

As described, the pathologist being sought reports to the Director of Blood Bank and Transfusion Services but focuses on blood utilization and patient blood management. This strikes me as being mainly about the why, what, who, and quantity questions relating to transfusion. The emergence of such a position strikes me as interesting. I don't mean to imply here that we did not pay attention to blood utilization four decades ago. We encountered frequent blood shortages that demanded blood management strategies, one example of which was the maximum surgical blood order schedule (MSBOS) (see: Hospitals Seek to Limit Blood Transfusions as a Cost-Saving Measure; Lower Blood Transfusion Rates as a Metric for High Quality Care; The Value of a Restrictive Blood Transfusion Strategy for Hospitalized Patients; Research that Transfusion of "Older" Blood May Be Harmful to Patients). However and to be honest, this blood inventory management tool was designed to limit the time that units of blood inappropriately aging in the OR blood refrigerators. The main idea was to primarily to limit inappropriate crossmatching rather than inappropriate transfusion. Most of our efforts regarding the inappropriate use of product was focused on platelet transfusions, either because the patient had developed immunity to them or to husband a scarce and expensive resource for patients who desperately need the product.

So why this new attention to blood management and utilization control? It's relates partly to the fact that, in some circles, blood transfusion is often deemed useless or even harmful to the patient (see: Avoiding Blood Transfusion as a Hospital Quality and Cost-Savings Measure; ). Secondly, younger physicians, and particularly surgeons, are now trained to use less or no blood. Lastly, blood and blood products are expensive. Curbing inappropriate use is one of the many facets of controlling the cost of healthcare.

I was a blood banker for nine years back in the 70's. For all that time, I was engaged in a constant struggle to increase the blood and blood product inventory while simultaneously tamping down demand, mainly from surgeons. One of the ways that I helped to reduce blood utilization and also increase useful shelf life of blood was with the maximum surgical blood order schedule (MSBOS) that placed limits on the number of units of crossmatched blood that surgeons could order preoperatively and store in the OR refrigerators (see: Hospitals Seek to Limit Blood Transfusions as a Cost-Saving Measure). Now, some four decades later, the tide is beginning to turn. Physicians are realizing that blood transfusion is not a panacea and may harm patients beyond the threat of transmission of infectious disease. Below is an excerpt from a recent article that discusses what appear to be a significant downturn in business for blood banks (see: AS DEMAND DWINDLES, US BLOOD BANKS MAKE CHANGES):

Blood banks are declaring fewer critical shortages these days and in some cases cutting staff in response to dwindling demand for blood - the result of fewer elective surgeries being performed and medical advances that curb bleeding in the operating room. The nation's blood-collection system has undergone a dramatic change from just a decade ago, when agencies that oversee the blood supply worried whether they could keep up with the needs of an aging population. Now blood banks are making fewer but more targeted appeals for donations and reducing the size of their operations. Blood centers shifted "from a collect-as-much-as-you-can mentality to a collect-to-need mentality," said Dr. Darrell Triulzi, medical director for the Institute for Transfusion Medicine in Pittsburgh and a former president of AABB...."They started collecting only what they needed. That's new to the industry. We're still learning how to do that well." Job cuts have been a part of the process.The Indiana Blood Center announced in June that it would eliminate 45 positions in a restructuring that also involved reducing its mobile operations, closing a donor center and cutting other costs because demand from hospitals had fallen 24 percent from the previous year. The Community Blood Center of the Ozarks in Springfield, Mo., announced in March that it was cutting staff by nearly 18 percent. Blood centers in Florida, West Virginia and Connecticut have taken similar steps....The need for blood is still falling even as the economy recovers. Demand dropped by 8.2 percent from 2008 to 2011 and continues to drop....Contributing to the decline are blood-management programs, which include collecting blood lost during an operation and returning it to the patient, maximizing hemoglobin levels to prevent anemia and using medications to reduce bleeding during surgery....Advances in surgical methods, including laparoscopic techniques that use small "keyhole" incisions, have also curbed the need for blood.

My gut instinct tells me that most of the decreasing demand for blood described above is based on three factors: (1) surgeons performing more laparoscopic procedures, including total hips, and adapting to the fact that patients can tolerate relatively low hemoglobin levels post-operatively; (2) pathologists and hospital executives paying even more attention to the cost of blood in this era of intense cost containment; and (3) patients exerting much more influence as consumers of healthcare services and being more aware of the complications of blood transfusion.

There was a time when I, in a previous incarnation as a blood banker, spent a lot of time thinking about the shelf life of blood and how to increase the utilization of blood in blood bank inventory. Hence, a recent article about this topic caught my eye, partly out of a sense of nostalgia (see: The Shelf Life of Donor Blood). Here is an excerpt from it:

For decades, the Food and Drug Administration has limited storage of refrigerated red blood cells to 42 days. But it has been clear for some time that stored blood degrades in various ways long before that six-week limit, and some research suggests that the changes may be harmful to patients who receive older blood. Now a study published in the journal Anesthesia & Analgesia has found that after even 21 days, the membranes of stored blood cells have stiffened, apparently the result of damage over time. That’s a problem because red blood cells are about the same diameter as small capillaries, and they have to change shape to get through.....“What we showed is that the cell membranes lose their flexibility,” said the lead author, Dr. Steven M. Frank....“That makes it more difficult for them to travel through.” The study also found that the older blood cells did not recover their flexibility after being transfused into patients, unlike certain other kinds of changes that blood cells undergo during storage. For example, nitric oxide, essential to keep blood vessels open, is depleted from cells after a few hours of storage, but is restored rapidly after transfusion. Still, researchers do not fully understand the importance of such findings to clinical practice. Even permanent changes in cell structure may not matter, according to [another expert]. “You constantly have blood cells that are getting old in your body, and they’re filtered out,” he said. “It may be that that same system harmlessly filters out these structurally abnormal blood cells.” Two large randomized clinical trials have been undertaken to clear up some of the uncertainties about stored red blood cells.....Dr. Richard J. Benjamin, chief medical officer at the Red Cross, said the two trials would provide important information. If older blood turns out to be less effective, he said, “there are a couple of ways we can respond.” “There are already better storage solutions in development that show drastically improved biochemistry parameters,” he said. “Is the next step to restrict the age of blood for vulnerable populations? ....” As the system works now, the newest blood goes to hospitals that do transfusions infrequently. This gives them time to store the blood safely until it is needed. But it leaves hospitals that use the most blood — trauma hospitals and academic medical centers — with the older blood.

Some highly esteemed hospitals now hold the view that most blood transfusions should be avoided. In short, they view blood transfusion with a jaundiced eye (see: Avoiding Blood Transfusion as a Hospital Quality and Cost-Savings Measure; The Value of a Restrictive Blood Transfusion Strategy for Hospitalized Patients). These hospitals are establishing policies to discourage transfusions on the basis of both cost and quality concerns. Such policies extend beyond the risk of transmitting infectious disease with the blood. I personally don't think that there will be a rapid drop in demand for blood regardless of the results of the two randomized clinical trials referred to in the excerpt above. It's often hard to get older physicians to accept new policies. Rather, I suspect that demand for blood may gradually level off and perhaps even go down slightly in the near future as these anti-transfusion policies extend beyond the few places where they have been already implemented.

The statement [from the article] ...that patients who "received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate" is quite dramatic and could probably be challenged. However, the fact that it even appeared in an article about the Cleveland Clinic's quality/cost containment initiatives, in my mind, is highly significant.

In reaction to that note, Dr. Claire Friedman submitted the following comment:

RESULTS: Overall, 30-day mortality was similar in the two [test] groups....However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill ...and among patients who were less than 55 years of age ... but not among patients with clinically significant cardiac disease....The mortality rate during hospitalization was significantly lower in the restrictive-strategy group ....

CONCLUSIONS: A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

I draw two major conclusions from this article regarding blood transfusion to hospitalized patients. The first point relates to the transfusion trigger, the factor or constellation of factors that precipitate a decision to transfuse blood. I and co-authors coined this phrase in an article published in 1980 (see: An Analysis of Blood Transfusion of Surgical Patients by Sex: A Quest for the Transfusion Trigger). The hemoglobin level has always been used by clinicians as one of the most important factors in assessing the need for blood transfusion. The hemoglobin level used in this regard seems to have trended downward by two or more grams during the last three decades. The second point in the article is that a "restrictive blood transfusion strategy" now seems to be gaining favor. I interpret this to mean that physicians prefer not to transfuse blood at all unless they are pushed to do so. Possible exceptions to this rule are patients with acute myocardial infarctions and unstable angina for whom oxygen delivery to damaged heart muscle takes precedence.

Tucked into a recent news article about the use of multidisciplinary teams (MDTs) at the Cleveland Clinic was the interesting mention of the goal of reducing blood transfusion as both a cost-savings measure and to reduce complications and survival after heart surgery (see: Approaching Illness as a Team). Below is the relevant paragraph:

Data analysis to evaluate how well treatments work is also a big part of the [Cleveland Clinic] medical practice. For instance, the clinic analyzed outcomes for heart surgery patients and found that those who had received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate. As a result, it has adopted strict guidelines that limit the use of transfusions. Such judgments about a treatment’s effectiveness are made by doctors, not by financial administrators, so they tend to be accepted....At the same time, the clinic has also carried out simpler reforms, like improving sterile conditions, which has reduced catheter-related bloodstream infections by more than 40 percent and urinary tract infections by 50 percent. All this has happened in a remarkably short time.

All physicians know that there are a number of potential adverse consequences associated with blood transfusions not the least of which is the transmission of infectious diseases (see: Blood transfusion). Blood suppliers and hospital blood banks, of course, run a battery of tests on crossmatched units of blood and components to try to avoid such complications as well as major incompatibility problems.

The statement above that patients who "received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate" is quite dramatic and could probably be challenged. However, the fact that it even appeared in an article about the Cleveland Clinic's quality/cost containment initiatives, in my mind, is highly significant. I am seeing a number of other similar article in prestigious journals (see, for example: GI Bleeding: Withholding Transfusion Boosts Survival).

The major reason that I helped to develop the Maximum Surgical Blood Order Schedule (MSBOS) several decades ago was to reduce the excessive number of units of blood that were crossmatched, stored in OR refrigerators, and never transfused (see: Hospitals Seek to Limit Blood Transfusions as a Cost-Saving Measure). However, another more subtle goal was to reduce the number of units transfused to patients simply because they were available in the OR refrigerators. I will see if I can get more information about the new "strict [blood transfusion] guidelines" that have been adopted by the Cleveland Clinic. I am enthusiastic about any measures that reduce unnecessary blood transfusion.

In my note yesterday, I began my personal interpretation of some of the most significant ideas that were discussed during the recent API Strategic Summit (see: Lessons from the API Strategic Summit: Beaker LIS Is Not "Free"). The conference was convened to discuss the future of the LIS and pathology informatics in the era of powerful EMRs. For today's note, I would like to discuss the term best-of-breed LIS. This topic was prompted by a question posed to me at the Strategic Summit by the president of the API, Ray Aller. He asked: why is is only now that we are beginning to grapple with a formal defintion for a best-of-breed (BOB) LIS? The answer is that for approximately four decades, there was no need to define a BOB LIS because everyone thought that they understood the term. In other words, there was a general consensus about the definition. This consensus now seems to be growing weaker.

Simply put, a BOB LIS is a system supplied by a single vendor with a broad range of modules and functionalities, each of which was deemed to be superior, or at least equal, to the competing systems in the market. It was also commonly understood that the LIS market was segmented by hospital/lab size so the return-on-investment (ROI) needed to be factored into this equation. An LIS designed for a large, complex lab might deliver too big and expensive a "payload" for a smaller lab so a different LIS might be considered BOB for that smaller lab segment.

It was axiomatic in the LIS world that the founders of LIS companies had emerged from the clinical lab industry or that the LIS vendors would always hire lab professionals to help design their software and serve as liaisons to lab clients. It was also axiomatic that there was an active "conveyor belt" for ideas about new lab functions between the hospital lab professionals and the LIS vendors. The goal was to continually enhance the LIS software as the overarching lab mission evolved and changed.

The definition for a BOB began to unravel when some vendors began to focus on the requirements of individual labs/functions such as blood bank, surgical pathology, or lab outreach. Some of these specialized vendors began to outshine the "classic LIS vendors" at their own game. In other words, they developed expertise in smaller and more specialized lab niches. An example today is whole-slide-imaging for which specialized vendors provide both hardware (i.e, slide scanners) and the requisite support software. Lab professionals responded by retaining their "classic LIS" but also purchasing these new systems and interfaced them to their classic LISs.

A new, competing model is now rapidly coming to the forefront -- the enterprise-wide-solution (EWS) such as that provided by Epic. Epic views the electronic medical record (EMR), the major software tool used by clinicians, as the epicenter of the hospital computing universe and the functionality requirements of diagnostic departments as subservient. In this Epic model, the company conceptually supplies "shrink-wrap" integration of all modules so that hospital CIO's don't have to deal with the previous "Tower of Babel." An EWS vendor like Epic need not strive to develop a BOB LIS. Beaker only needs to be "good enough" because of the overall appeal of the value proposition of the Epic EMR to CIOs. In response, the hospital lab leadership needs to patch the lab functionality gaps opened by Beaker by deploying "specialized" lab systems or retain their BOB LISs. This is optimistically viewed as a stopgap measure until Epic delivers all the required software solutions.

We have just completed the API Strategic Summit, a gathering of pathology informaticians and lab professionals from across the country in Pittsburgh underwritten by Cerner, Sunquest, McKesson, and SCC Soft (see: Attend the Strategic Summit: Help Decide the Future of the LIS and Pathology Informatics). The conference consisted of a total of 12 lectures over an evening and a day. Its focus was an analysis of the future of the LIS and pathology informatics in the era of dominant EMRs. More detailed strategic questions that were addressed at the conference are available on the API web site.

The first lecture on the evening of June 7, 2012, was by Mike Becich who discussed the future of pathology and personalized medicine. The next day's schedule consisted of a total of 11 lectures, four by representatives of the corporate underwriters and seven others by faculty members selected on a competitive basis. A white paper is now under development that will provide a formal summary of the entire event. Meanwhile, I want to present, in a series of blog notes on Lab Soft News, what I personally consider the major take-away lessons from the conference.

Epic is rapidly becoming the most common EMR to in hospitals 500 beds or larger and grabbing most new contracts and installs. The company offers an LIS called Beaker as one of its modules as part of its business model of providing an "enterprise wide solution" (EWS). One commonly hears on the street that Beaker is free. This assertion requires significant qualification. If lab professionals accept this idea at face value, their future careers clould be in serious jeopardy. Beaker is "free" only in the sense that its software licensing fee is wrapped up in up-front price paid for the Epic EWS by hospitals. However and more importantly, there are significant installation costs involved in bringing Beaker live. Two LIS consultants present at the Strategic Summit estimated the current installation costs for Beaker at about $800,000 to $1,400,000, depending on hospital size. These are only estimates and may vary by deal and individual negotiations. By way of contrast, a fully-functional, best-of-breed LIS for a medium-sized hospital would cost roughly $2,000,000 for licensing fees and installation. However, the functionality of Beaker is significantly limited.

I was also told by faculty and attendees at the Strategic Summit that Beaker provides good functionality for chemistry and hematology and average or sub-average functionality for microbiology and surgical pathology. There are no blood bank or molecular pathology modules at this time or a lab-oriented outreach product (see: Details about Epic's Beaker LIS, Supplied by the Company). Lab rules capability is limited to what is offered by the Data Innovations "middleware" that is baked into Beaker with most of the rules focused on chemistry and hematology. Beaker plus the additional software that must be installed to achieve the necessary lab functionality may well end up costing the same or more than a best-of-breed system that begins with broad functionality. In addition and with the "Beaker plus" (i.e., hybrid) design approach, the lab is faced with a major system integration headache.

Given these circumstances, the question needs to be asked why would the lab leadership choose to install the immature Beaker product at all. From my perspective, there are two possible reasons. The first is to satisfy their hospital executives who may be laboring under the misapprehension that Beaker is free and also eager to please Epic with another Beaker install. The second reason is to provide lab professionals working in the hospital the "opportunity" to teach the Epic personnnel how to manage lab workflow and lab computing. As presented in a previous note posted in August 2011, the company reported that it had assigned about 50 employees out of more than 4,000 to LIS development, installation, and support (see: Here Comes Epic's Beaker LIS -- Ready or Not). This number may be larger now. I was told at the Strategic Summit that the company has almost no "lab experts" on the payroll as most of us would define the term. The commpany is going to need a lot of help to turn Beaker into a mature, best-of-breed LIS.

Facebook founder Mark Zuckerberg seems to be constantly in the news, partly due to the recent problematic IPO of the company. One of the stated goals for his wildly successful social media web site is to change society for the good and this goal extends to organ donation (see: Facebook encouraging organ donations). Here is an excerpt from a CNN article about this topic:

On average, 18 people in the United States die each day waiting for an organ transplant. Billionaire Facebook co-founder Mark Zuckerberg wants to change that. He announced...that the social networking site wants to "help solve the crisis" by allowing users to volunteer as potential organ donors in the United States and the United Kingdom....He described widespread acceptance of organ donation as "a shift in society that will probably take a while to fully take hold" until more Facebook users start sharing their experiences.

Last October a team of researchers at Loyola University Medical Center began tracking how Facebook was being used as a tool for connecting potential donors with those in need of an organ. The researchers focused on kidney solicitations in particular and studied 91 Facebook pages seeking kidney donations for patients ranging in age from two to 69. Of the Facebook pages studied, 12 percent reported receiving a kidney transplant and 30 percent reported that potential donors had stepped forward to be tested to determine whether they were compatible....One page reported that more than 600 people had been tested as potential donors for a young child.There was a broad range in terms of how much personal information people disclosed. Some Facebook pages simply asked people to donate, without providing any other information. Other pages provided great detail about patients who needed kidneys, including explicit medical histories and family photos as well as emotional accounts of hospital stays, emergency room visits, financial problems and the difficulties of living on dialysis, according to the researchers....The research findings also raised ethical concerns: 3 percent of the pages received offers to sell kidneys, mostly from people in Third World countries. Would-be donors typically asked for $30,000 to $40,000, even though selling organs is illegal in most countries. In addition, only 5 percent of pages mentioned the risks of kidney donation....and only 11 percent mentioned associated costs.

With close to a billion subscribers (see: Number of Facebook users could reach 1 billion by 2012), Facebook will reflect global markets in everything. It should thus come as no surprise that commercial traffic in organs on Facebook has surfaced. I had a recent conversation with an individual who lives outside of the U.S. A relative of hers traveled to the Philippines for a kidney transplant. She was well aware that the organ donor was being paid for the service. I had the sense during the conversation that the entire process was institutionalized and relatively routine. There is a long history of "regulated compensation" for kidney donors in the Philippines (see: Regulated compensation for kidney donors in the Philippines). Sporadic attempts have been made to regulate it over the years.

For many people in developing countries, the price paid for an organ donation is a windfall that can change their lives and that of their families. They are willing to take the risk that accompanies the procedure (see: Organ Trafficking and Transplant Tourism: A Commentary on the Global Realities). Donor kidneys these days are frequently removed via laparoscopy so that the risk of the procedure for the donor is minimized and post-operative recovery is rapid. Normal renal function, as measured by the level of serum creatinine of the kidney donor, is achieved in a few days.

Dashing the hopes of many people with chronic fatigue syndrome, an eagerly awaited study coordinated by government health agencies has not confirmed a link between the illness and a virus called XMRV or others from the same class of mouse leukemia viruses. Two research groups had earlier reported an association between chronic fatigue syndrome and the group of viruses, known as murine leukemia viruses, or M.L.V.’s, raising hopes that a treatment or cure could be found. But later studies did not substantiate the link, and many researchers suggested that that the initial findings were the result of contamination of laboratory samples or equipment....Vincent Racaniello, a microbiology professor at Columbia University who has covered the controversy on his popular virology blog, said the XMRV/M.L.V. hypothesis was now dead....An estimated one million Americans suffer from chronic fatigue syndrome. Countless studies have documented immunological, neurological and other physiological abnormalities. Despite the name of the illness, patients have long reported that simple fatigue is not their cardinal symptom but rather what researchers call postexertional exhaustion — a profound depletion of energy after even minimal exercise or activity. Recently, a panel of top researchers proposed a new definition of the illness that requires the presence of postexertional exhaustion, rather than the six months of unexplained fatigue required under the standard definition. The group also recommended changing the name to myalgic encephalomyelitis, a virtually identical illness long recognized by the World Health Organization. “Internationally recognized experts have looked at the immune data and concluded that there very well may be a pathogen or pathogens involved in the persistence of this illness,” [a disease expert] wrote in an e-mail message.

Here's what I personally learned from this article:

There does not appear to be a link between chronic fatigue syndrome and the XMRV/MLV group of viruses.

Patients with this syndrome do not generally complain of simple fatigue but rather postexertional exhaustion.

The chronic fatigue syndrome is now considered to be identical to a long-recognized disease called myalgic encephalomyelitis.

The irony about the XMRV "red herring" for chronic fatigue syndrome is that it seems to have opened up more serious inquiries about the viral etiology of the disease, resulting in a merger with another disease, myalgic encephalomyelitis (ME). Here is a brief summary about the causality of ME:

Although risk factors for myalgic encephalomyelitis have been identified, no single definitive virus has been found in all cases, which has lead to the claim that ME is a common end path of a variety of infectious insults, perhaps most commonly in the retroviral family. It is still possible ME involves some combination of both environmental and genetic factors....Although most accept an infectious explanation, several theories suggest that ME is an inappropriate immune response to an underlying condition, a theory bolstered by the observation that there is sometimes a family history of autoimmune disease. There is also a shift from the Th1 type of helper T-cells, which fight infection, to the Th2 type, which are more active in allergy and more likely to attack the body.

Generally speaking, I think that the amount of blood transfused to a patient can and should be used as a metric for the quality of care delivered by physicians, particularly surgeons. I have long been aware of differences in transfusion rates by hospitals or by regions of the country. Much of this can be explained by local customs and norms rather than well defined standards of care. When I was a blood banker back in the 1970's, one of the hospital cardiac surgeons would frequently transfuse six units of blood for a CABG when type-and-screen was the common blood order for the same procedure at the Cleveland Clinic. Once again, or perhaps still, the amount of blood being transfused is in the news. (see: Too many blood transfusions? New standards urged). Below is an excerpt from a recent article. Not much new, at least for me, but worth emphasizing:

There's a lot of variation around the country in how quick doctors are to order up a few pints — not in cases of trauma or hemorrhage where infusing blood fast can be life-saving, but for a range of other reasons....Now a government advisory committee is calling for national standards on when a transfusion is needed — and how to conserve this precious resource. All the variability shows "there is both excessive and inappropriate use of blood transfusions in the U.S.," advisers to Health and Human Services Secretary Kathleen Sebelius concluded earlier this month. "Improvements in rational use of blood have lagged."....The U.S. uses a lot of blood, more than 14 million units of red blood cells a year. Between 1994 and 2008, blood use climbed 40 percent, [an expert] told the HHS Advisory Committee on Blood Safety and Availability. In many years, parts of the country experienced spot shortages as blood banks struggled to bring in enough donors to keep up....One study published last fall tracked more than 100,000 people who underwent open-heart surgery, a transfusion-heavy operation. Just 8 percent of those patients received transfusions at some hospitals, while a startling 93 percent did at other hospitals. But survival wasn't significantly different at hospitals that used more blood than at hospitals that used less....Overall, the U.S. uses about 49 units of blood for every 1,000 patients, substantially more than Canada or Britain where those transfusion rates are in the 30s....Consider Eastern Maine Medical Center. Transfusion chief Dr. Irwin Gross described how doctors now order blood via a computerized form that warns if they're about to deviate from the guidelines and tracks who uses the most.

The primary goal of the MSBOS is to reduce blood wastage. It achieves this goal in two ways. First of all, surgeons will sometimes transfuse crossmatched blood on-hand in the OR even in marginal cases. Secondly, crossmatched but untransfused blood returned to the blood bank has used up some of its valuable shelf life, thus reducing its intrinsic value. The adoption of a MSBOS program two effects -- it increases the effective blood supply for those patients with a legitimate need for it and also reduces the cost of operating a hospital blood bank by reducing the discard rate for outdated blood.

If you are scheduled for an elective surgical procedure, ask the surgeon whether he or she agrees with the premise that better surgeons use less blood intra- and post-operatively. A follow-on question is to ask about his or her average blood use for the procedure and how it compares to peers. Regardless of the response, you will have made a key point.